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Health Management, Ethics and Research Module: 7.  Principles of

Healthcare Ethics
Study Session 7  Principles of Healthcare Ethics
Introduction
Ethics is about the values that should be respected by all healthcare workers while interacting with individuals, families and
communities. Ethics may sometimes be considered a scary term by some healthcare professionals because it is a word that may
bring to mind an accusation of wrongdoing or mistakes, but this is not the case.

In this study session you are going to cover the concepts and principles of ethics that are relevant to your work as a Health Extension
Practitioner. This will enable you to identify some of the most important ethical issues and then find out how to work to resolve them.
Working to clear, consistent ethical principles is one of the most important components for delivering quality healthcare for individuals,
families and the community at large.

This study session mainly focuses on ethical issues that you may face in your day-to-day practice and introduces some of the
mechanisms you can use in order to resolve them.

Learning Outcomes for Study Session 7

When you have studied this session, you should be able to:

7.1  Define and use correctly all of the key words printed in bold. (SAQs 7.1, 7.2, 7.3 and 7.4)

7.2  Describe the basic principles of confidentiality and truthfulness. (SAQ 7.1)

7.3  Describe the basic principles of autonomy and informed consent. (SAQ 7.2)

7.4  Describe the basic principles of beneficence and nonmaleficence. (SAQ 7.3)

7.5  Describe the basic principles of distributive and social justice. (SAQ 7.4)

7.6  Illustrate your understanding of the ethical theories covered in this study session through the use of examples and case studies.
(SAQ 7.5)

7.1  Ethical issues in healthcare work

Your work as a Health Extension Practitioner will involve ethical issues – even if you are not really aware that this is the case.
Everybody has ethical issues in their lives and ethical theory can help us all to understand these issues – and work out ways of
dealing with them.

Ethics is the branch of philosophy (Box 7.1), which takes a systematic approach to define social and individual morality – the
fundamental standards of right and wrong that a whole society, as well as individuals, learn from their culture and peers. Perhaps you
have already started to think about some things in your own life where you have had to take important decisions that might have an
ethical component? For example, how should you look after your family when conflicts arise?

How should you deal with people in your community who present you with problems that are difficult to resolve? All these aspects of
living your life involve ethical issues (Figure 7.1).
Figure 7.1  Ethics is not a remote subject but is part of everyday life. The way that any society looks after its families, for example, is
an ethical issue. (Photo: FMOH/WT)

Box 7.1  What is philosophy?

Philosophy is the study of general and fundamental problems, such as existence, knowledge, values, reason, mind and
language. It is distinguished from other ways of addressing such problems by its critical, generally systematic approach and its
reliance on rational argument.

7.1.1  Two important ethical theories

In this study session you will learn about two of the most relevant ethical theories for your professional practice as a Health Extension
Practitioner. These are called utilitarianism and deontology.

Utilitarianism considers an action as morally right if its outcomes or consequences are good for the greatest number of the population.
It focuses on ‘the greatest good for the greatest number’. This theory disregards individual rights and considers the welfare of the
greatest majority to be the most important factor. For example, it might be necessary to drain a particular pond because it is the
breeding ground for mosquitoes – although this might be difficult for the farmer on whose land it is situated (Figure 7.2). In this
situation the welfare of the greatest number of people is more important than the rights of the individual farmer.

Figure 7.2  Draining a mosquito breeding ground may be difficult for the farmer but be good for the health of everybody in the
community. (Photo: Ali Wyllie)

Deontology, on the other hand, considers the way that things are done rather than focusing just on the consequences. This type of
ethics holds at its core the respect for fundamental rights, such as the right to truth, privacy and the fulfilling of promises (Figure 7.3).
Deontology considers the rightness or wrongness of an action. For instance, someone who believes that lying is always wrong, even if
a lie might accomplish some good for individuals and society, is following the principles of deontology – although they may never have
heard of the theory.

Figure 7.3  It is always important to be clear and truthful about health issues such as the use of contraception. (Photo: Ali Wyllie)

Imagine that a healthworker tells a mother of ten children that if she takes oral contraceptive pills they will be 100% effective in
preventing another pregnancy, and that the pills have no side-effects. Is this approach an example of utilitarianism or deontology?

Reveal answer

7.2  Ethics in practice
In this section you will be able to learn some of the key principles that will help you to think about ethical decisions which you may
come across in your work.
The five main principles of ethics are usually considered to be:

Truthfulness and confidentiality

Autonomy and informed consent

Beneficence

Nonmaleficence

Justice.

Some of these are difficult words, but in this study session you will be able to consider each of them in turn, using examples that will
be familiar to you. This will help you to see how ethical principles are present in almost every aspect of your health work and daily life.

7.2.1  Truthfulness and confidentiality

Two concepts that you may commonly face in your day-to-day practice are truthfulness and confidentiality. Truthfulness is about
telling the truth to someone who has the right to know the truth. For example, if you have been informed about the result of an HIV test
taken by someone in your community who then asks to know his/her result, you should tell the person the truth even though this might
be very upsetting to that person. The concept of truthfulness urges the professional not to lie.

On the other hand, the concept of confidentiality urges you to keep a secret – by which we mean knowledge or information that a
person has the right or obligation to conceal (Figure 7.4). For example, if the family of a person who has had an HIV test demands
that you give them the result, you must not tell them. You must keep the result confidential unless your client gives you permission to
tell their family.

Figure 7.4  If the client knows that the healthworker is always going to work with the ethical principle of confidentiality in mind, then
they will be able to talk freely about sensitive issues. (Photo: UNICEF/Indrias Getachew)

The professional obligation to keep a secret arises from the fact that harm will almost certainly follow if the information is revealed.
There are three types of secrets:

Natural secret: information which, if revealed, is harmful by its nature.

Promised secret: information that we have promised to conceal which, if broken, leads to public mistrust.

Professional secret: knowledge which, if revealed, will harm the client, the profession and the society that obtain services from
the profession. A professional secret is the most serious of all secrets, because its violation can cause the greatest harm.

Case Study 7.1  Chaltu faces a dilemma

Chaltu, a Health Extension Practitioner, is responsible for providing community healthcare for 2,500 households including Mr
Gadisa’s family.

Mr Gadisa’s life is based on farming. He does not have any extra income other than the income he gets from farming. One morning
Chaltu went to Mr Gadisa’s house to provide health education on family planning to W/ro Bekelech, wife of Mr. Gadisa. While she
was having a conversation with her, Almaz, their sixteen-year-old daughter, interrupted the conversation and asked Chaltu to sit
and discuss a private health issue with her.

Almaz began by telling Chaltu that this is a private issue and that she should not tell this to anyone, even her parents and other
family members. She said, ‘I have a serious problem. Please listen to me attentively. Three months ago, when I went to fetch water
for my parents from a lake which is located 3 km away from my house, I was raped by someone whom I don’t know. I saw my last
 menstruation three months ago. In addition I have a foul-smelling discharge from my birth canal. I regularly wash my genitals to
remove the discharge, but I can’t get rid of this discharge. Now I am asking you to provide me with medicine for my problem and
help me with sisterly advice.’

Chaltu sat sadly for a long period of time without giving her a response, thinking about what to do in her mind.

a. What ethical issues do you think are raised in Case Study 7.1?

b. Which of the following do you think that Chaltu should do? Explain your reasons.
Option 1: Do nothing and hope that someone else deals with this problem.

Option 2: Tell Almaz that she must immediately tell her parents what has happened to her.

Option 3: Refer Almaz to the health centre for pregnancy testing and treatment of her infection.

Option 4: Ask Almaz to come to see her at a place that will be confidential so that more details can be found out.

Reveal answer

Case Study 7.1 clearly concerns the issue of confidentiality between a health practitioner and a client. It also raises a number of
issues about autonomy and informed consent which you will learn about next.

7.2.2  Autonomy
Autonomy is another ethical principle that you may already be aware of, but not know by that name. The term refers to every
individual’s right of self-determination, independence and freedom to make their own choices. In the context of healthcare, the concept
of autonomy is most concerned with the ethical obligation of the practitioner to respect their clients’ right to make decisions about their
own health. Autonomy must be respected even if you, as the healthcare provider, do not agree with the client’s decision. For example,
in Case Study 7.1, Chaltu may feel that Almaz’s parents should know what has happened to their daughter, but you must respect
Almaz’s right to maintain confidentiality about her condition.

However, there are conditions in which that personal choice or autonomy may be restricted because of concern for the wellbeing of
the community. For instance, if a communicable disease, such as tuberculosis, is diagnosed, clients can be required to take
prescribed medication and may have to be isolated to prevent the spread of the infectious agent to others.

7.2.3  Informed consent
Informed consent means that each person who has any sort of procedure done to them in a healthcare context should give their
approval for that procedure to be done to them. In order to be fully informed, it is the duty of the healthcare worker to tell the person
exactly what the procedure will involve as well as the things that might happen if the procedure is not carried out. In Case Study 7.1 it
is clear that Almaz will need further treatment at the health centre and that she will need to give her informed consent for this to take
place. There is an ethical obligation on Chaltu, her Health Extension Practitioner, to explain to Almaz what will happen at the health
centre, but also the possible consequences if she does not attend.

Which of the following healthcare procedures that might be undertaken by a Health Extension Practitioner require informed
consent?

a. Getting the community together to construct a new latrine.

b. Immunizing a pregnant woman with tetanus toxoid.

c. Testing a young boy to see if he has malaria.

d. Distributing an Insecticide Treated Bed Net (ITN) to a family.

Reveal answer

Informed consent is implied in much of the work that Health Extension Practitioners do. In other words if a mother brings her child to
the Health Post to be immunized, informed consent is necessary because the Health Extension Practitioner is performing a procedure
that has benefits, but may also have side-effects. However, the act of bringing the child for the procedure implies consent, as does
attending for a contraceptive injection (Figure 7.5). But Health Extension Practitioners should always explain what they are doing and
how it impacts on individuals, their families and the wider community.
Figure 7.5  Informed consent for immunization must be given before any procedure is undertaken. (Photo: Ali Wyllie)

7.2.4  Beneficence and nonmaleficence

Beneficence is pronounced ‘be-neffi-sens’.

Nonmaleficence is pronounced ‘nonma-leffi-sens’.

In this section you will be able to learn about two important ethical concepts which may be new to you, but which are relevant for your
practice. These are called beneficence and nomaleficence. The term beneficence tells you about ‘doing good’ for your client, for
instance by providing immunization.

From your own experience of receiving or witnessing health services at community level, can you suggest some examples of health
interventions that demonstrate beneficence by health workers?

Reveal answer

On the other hand, the concept of nonmaleficence tells you to ‘do no harm’ either intentionally or unintentionally to your clients, for
instance, not abandoning a client who is in need of your services. As you have seen in Case Study 7.1, Chaltu must not abandon
Almaz and leave her to manage her problems without professional help. However, there are circumstances in which it is impossible to
‘do good’ and ‘avoid doing harm’ all at the same time. For instance, you may plan to provide birth control to all the women in your
locality who are in need of it, but resource availability, cultural beliefs of the community, clients’ reaction to the service and other
factors can limit you from doing good to the greatest number. Moreover, you cannot always avoid doing harm to a client; for instance,
in times when a communicable disease arises in your vicinity, you may have to suggest isolating individuals with the infection against
their will to contain the spread of the disease and for the good of the majority.

7.2.5  Justice
In Sections 7.2.1 to 7.2.4 you studied the concepts of confidentiality, autonomy, informed consent, beneficence and nonmaleficence.
In this final section, you will be able to learn about the concept of justice, which is an important concept that will help you during your
interaction with individuals, families and communities at large.

Justice is a complex ethical principle and it entails fairness, equality and impartiality; in other words, it is the obligation to be fair to all
people. Most Health Extension Practitioners will understand about justice without necessarily having come across the word itself. The
concept of justice will become clearer if you understand the meaning of two categories of justice: distributive justice and social justice.

Distributive justice means that individuals have the right to be treated equally regardless of ethnic group, gender, culture, age,
marital status, medical diagnosis, social standing, economic level, political or religious beliefs, or any other individual characteristics.
Everyone should be treated in the same way.

Social justice is based on the application of equitable rights to access and participation in all aspects of goods and services provided
in a society, regardless of their individual characteristics. Everyone should have access to the same things that might improve their
health. As a Health Extension Practitioner, you will be able to carry out distributive and social justice by enabling the inclusion and
empowerment of all people living within your area to exercise their rights (Figure 7.6). You can understand the concept of justice from
the examples in Case Study 7.2.
Figure 7.6  Justice will have been delivered when all individuals and members of all society are treated in exactly the same way by the
health service. (Photo: Ali Wyllie)

Case Study 7.2  Justice challenge

Example 1: Suppose a Health Extension Practitioner, Fantaye, visits Mr Lemma’s family to carry out routine antenatal care and
check the pregnancy status of Mr Lemma’s wife, W/ro Lemlem. The family of the Health Extension Practitioner has a family dispute
with Mr Lemma’s family and she only spends a few minutes with W/ro Lemlem and doesn’t tell her about all the services that are
available for women when they are pregnant.

Example 2: Another Health Extension Practitioner is working in a community which is spread out over a large rural area. She is too
lazy to go to the farthest homes to invite them to participate in an environmental sanitation campaign.

Look at the two examples in Case Study 7.2. Are these examples where social justice or distributive justice is not being carried
out?

Reveal answer

Why is justice important?

If you are not fair to individuals and community groups in your vicinity while practising your profession, you will not be able to gain
public trust and this will negatively affect your practice. As a Health Extension Practitioner you should be fair and maintain high ethical
standards at all times, including confidentiality and truthfulness towards all your clients equally. However, as some of the examples in
this study session have shown, you will be faced with dilemmas that are difficult to resolve in harmony with the concepts of respecting
autonomy and informed consent, and reconciling the demands of beneficence and nonmaleficence. In Study Session 8 there will be
further examples of ethical dilemmas for you to think about and learn from.

Summary of Study Session 7

In Study Session 7, you have learned that:

1. Ethics is the branch of philosophy that takes a systematic approach to help decide what is right or wrong for society as well as
for each individual. Utilitarianism considers an action as morally right if its outcomes or consequences are good for the greatest
number. Deontology considers duty above the consequences or outcomes of any action and gives priority to respect for
fundamental rights, such as the right to truth, privacy and the fulfilling of promises.

2. Confidentiality and truthfulness are fundamental to the work of healthcare workers at every level of the health service. Without
working to these basic principles healthcare workers will not gain the respect of their community.

3. Beneficence is about ‘doing good’, for example by providing immunization for babies and children in your community.
Nonmaleficence is about ‘doing no harm’, for instance not abandoning your client and making sure all your actions are carefully
considered.

4. Justice is the obligation to be fair to all people regardless of their individual characteristics, such as age, gender, religion,
ethnicity, culture, economic status or political views.

Self-Assessment Questions (SAQs) for Study Session 7

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering
the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting.
You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 7.1 (tests Learning Outcomes 7.1 and 7.2)

Why do you think it is important for health workers to stick to the ethical principles of confidentiality and truthfulness at all times?

Hide answer

Answer
As a Health Extension Practitioner working in a community, you should always work towards building up community trust. Telling
the truth (truthfulness) and keeping clients’ private issues to yourself (confidentiality) are basic principles that you should always
stick to during your day-to-day relationships with people. If you are not trustworthy, individuals will keep away from your services for
fear that their private issues will be disclosed. This has the potential to severely affect your practice.

SAQ 7.2 (tests Learning Outcomes 7.1 and 7.3)

What is informed consent?

Reveal answer

SAQ 7.3 (tests Learning Outcomes 7.1 and 7.4)

Can you give an example of beneficence and an example of nonmalefience that a Health Extension Practitioner might
demonstrate?

Reveal answer

SAQ 7.4 (tests Learning Outcomes 7.1 and 7.5)

What is the difference between distributive justice and social justice? Give an example of each type of justice that relates to the
healthcare system.

Reveal answer

SAQ 7.5 (tests Learning Outcome 7.6)

Imagine that Hamelmal, a 17-year-old, is now three months pregnant as the result of a rape attack. She had a baby last year that
she decided to keep with the help of her family, with whom she lives. She has been attending High School and had hoped to
complete next year. However, she dropped out of school recently as she had not been feeling very well with this pregnancy.

You are the Health Extension Practitioner caring for Hamelmal. Her mother wants her to have an abortion because of the rape and
because she already provides most of the care for Hamelmal’s first child. Hamelmal, however, refuses to have an abortion, saying
that she loves this baby and is praying the baby will be healthy.

What are the ethical issues or concerns in this situation?

Reveal answer